GW1-2023-02327_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD (OW-1) For Internal Use Only:
1.Well Contractor Information:
�5 rP11 � 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
q'S 7 22 - � 94 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if applicable)
Water Wizards Inc FROM TO I DIAMETER THICKNESS 11 MATERIAL
/ ft- 7 ft. t in. J 51t,1
Company Name v
-036
A 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: , FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variancenc,etc — ft. �1 ft. in. C O
3.Well Use(check well use): ft. v ft. in. V
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public 0 ft, ft, in.
I_ Geothermal(Heating/Cooling Supply) ZResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
lrrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ne d
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:- Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
!_ Geothermal(Closed Loop) iOTracer 20.DRILLING LOG attach additional sheets if necessary)
I—IGeothermal(Heating/Cooling Return) 00ther(ex lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.
ft. ft.
4.Date Well(s)Completed: Well ID#
Sa.Well Location: ft. ft.
^
Facility/Owner Name Facility ID#(if applicable) ft.
MAR
ft. ft. MAR
Physical Address,City,and 2 p
t�fd� 21.REMARKS y
County _T Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
3G.1323110, N - ]I - M9724:5 W
6.Is(are)the well(s) Permanent or Temporary Si ature of Certified Well Contractor Date
40 ,,,---���((( By signing this form,1 hereby certify th t well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or FJNo with 15A NCAC 02C.0100 or 15A NCA 02C.0200 Well Construction Standards and that a
If this is a repair,fill out,t7wwn well construct,n information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft,) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well constriction method:
above,also submit one copy of this form within 30 days of completion of well
�n�ufl1(i.e.auger,rotary,cable,direct push,etc,) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY[WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _!S Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ���i completion of well construction to-the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016